guidance on completing a written allergy and anaphylaxis emergency plan · pediatrics volume 139 ,...
TRANSCRIPT
FROM THE AMERICAN ACADEMY OF PEDIATRICSPEDIATRICS Volume 139 , number 3 , March 2017 :e 20164005
Guidance on Completing a Written Allergy and Anaphylaxis Emergency PlanJulie Wang, MD, FAAP, a Scott H. Sicherer, MD, FAAP, a, b SECTION ON ALLERGY AND IMMUNOLOGY
aDivision of Pediatric Allergy and Immunology, and bProfessor of Pediatrics, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, New York
Dr. Wang drafted the initial report, revised the document for critically important intellectual content on the basis of comments from AAP reviewers, and contributed to writing the fi nal manuscript. Dr. Sicherer contributed to the initial drafting and editing at all stages, including the fi nal manuscript. Drs. Wang and Sicherer approved the fi nal version to be published and agree to be accountable for all aspects of the work.
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have fi led confl ict of interest statements with the American Academy of Pediatrics. Any confl icts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
Clinical reports from the American Academy of Pediatrics benefi t from expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not refl ect the views of the liaisons or the organizations or government agencies that they represent.
The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffi rmed, revised, or retired at or before that time.
DOI: 10.1542/peds.2016-4005
Julie Wang, MD. E-mail: [email protected]
abstractAnaphylaxis is a potentially life-threatening, severe allergic reaction. The
immediate assessment of patients having an allergic reaction and prompt
administration of epinephrine, if criteria for anaphylaxis are met, promote
optimal outcomes. National and international guidelines for the management
of anaphylaxis, including those for management of allergic reactions at
school, as well as several clinical reports from the American Academy of
Pediatrics, recommend the provision of written emergency action plans to
those at risk of anaphylaxis, in addition to the prescription of epinephrine
autoinjectors. This clinical report provides information to help health
care providers understand the role of a written, personalized allergy and
anaphylaxis emergency plan to enhance the care of children at risk of
allergic reactions, including anaphylaxis. This report offers a comprehensive
written plan, with advice on individualizing instructions to suit specifi c
patient circumstances.
CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care
INTRODUCTION
Anaphylaxis is a potentially life-threatening, severe allergic reaction. 1 As
such, it is a medical emergency that requires an immediate assessment of
the patient and administration of epinephrine. Given the unpredictable
nature of anaphylaxis, preparedness promotes optimal outcomes. Thus,
national and international anaphylaxis guidelines, as well as several
American Academy of Pediatrics (AAP) clinical reports (“Self-injectable
Epinephrine for First-aid Management of Anaphylaxis, ” “Management of
Food Allergy in the School Setting, ” and “Medical Emergencies Occurring
at School”), recommend the provision of emergency action plans to
pediatric patients who are at risk of anaphylaxis, in addition to the
prescription of epinephrine autoinjectors. 2 – 7 Guidance from the Centers
for Disease Control and Prevention for managing food allergy in schools
and early education programs also supports the inclusion of written
emergency plans for the management of children with food allergy. 8
To cite: Wang J, Sicherer SH, AAP SECTION ON ALLERGY AND
IMMUNOLOGY. Guidance on Completing a Written Allergy
and Anaphylaxis Emergency Plan. Pediatrics. 2017;139(3):
e20164005
by guest on June 26, 2020www.aappublications.org/newsDownloaded from
FROM THE AMERICAN ACADEMY OF PEDIATRICS
Written action plans have been
shown to improve outcomes for
asthma, 9 and similarly, action plans
have the potential to improve
outcomes of anaphylaxis by reducing
the frequency and severity of
reactions, improving knowledge
of anaphylaxis, improving use of
epinephrine autoinjectors, and
reducing anxiety of patients and
caregivers. 10 Action plans serve as
an important tool for anaphylaxis
education and treatment.
Currently, several different
anaphylaxis action plans are
available, but variations exist
in content and treatment
recommendations, which can lead
to confusion. A survey of AAP
Section on Allergy and Immunology
members found that there is wide
variation in terms of which plans
are used by pediatric allergy
specialists. 11 Therefore, a universal
plan for pediatric patients could be
beneficial to patients, families, health
care professionals, and schools to
facilitate care for children at risk
of anaphylaxis. The AAP Allergy
and Anaphylaxis Emergency Plan
associated with this clinical report
was developed with the support
and advice of various committees,
councils, and sections within the
AAP. It is available online (www. aap.
org/ aaep) and shown in Fig 1. This
plan takes into consideration several
aspects of anaphylaxis emergency
care, including the recognition of
signs and symptoms and treatment.
This clinical report focuses on
providing guidance to the clinician to
complete the plan. The guidance in
this clinical report has not undergone
a systematic review nor a strict
weighing of the evidence and, as such,
should not be considered a practice
guideline. Clinical guidance regarding
treatment with epinephrine in the
first-aid management of anaphylaxis
is covered in a separate clinical
report. 5
WHEN TO PROVIDE A WRITTEN EMERGENCY PLAN
An allergy and anaphylaxis
emergency plan, developed by the
health care provider, is a document
written in simple lay terms that
can guide the patient, family and
nonfamily caregivers, and school
personnel in the event that the child
experiences an allergic reaction.
Allergic reactions can occur
anywhere and at any time, and health
care providers may not be present
at the time a child has an allergic
reaction. Therefore, the emergency
action plan serves as a guide for the
patient, caregiver, and/or school
personnel to determine how to treat
allergic reactions.
It is beneficial to provide an allergy
and anaphylaxis emergency plan
when there is a diagnosis of an
allergic disorder that places the
child at risk of anaphylaxis (eg, food
allergy, insect sting allergy). A new
written plan can be provided, for
example, annually at the beginning
of the school year, to address any
need for adjustment of medication
doses or whenever there is any
change in allergic triggers, comorbid
conditions, or any new medical
information that would warrant a
change in the plan.
COMPLETING THE ALLERGY AND ANAPHYLAXIS EMERGENCY PLAN
Demographic Information and Allergy History
The initial section is completed with
the child’s demographic information,
including name, date of birth, and
age, as a personalized plan for the
child. The plan should be dated so
that it is easy to determine when
the health care provider created the
emergency plan. Allergic triggers can
be listed in the space provided. It is
advisable to include the weight of the
child at the time the plan was created
to allow confirmation of correct
medication dosages.
Having a history of asthma and/or
of anaphylaxis is associated with a
higher risk of severe reactions and, as
such, these should be noted. 12, 13 The
presence of asthma is associated with
an increased likelihood of having
respiratory symptoms during an
allergic reaction and can cause the
reaction to be more difficult to treat.
In a recent study of anaphylaxis-
related hospitalizations over 2
decades in the United Kingdom, 75%
of patients with fatal food-induced
anaphylaxis were noted to have
concurrent asthma. 14
A child’s ability to self-carry
emergency medications and/or
self-administer medications can be
indicated. This ability will depend on
the age and maturity of the child. All
states have laws to allow self-carry
by students in schools; however,
some states require a student’s
physician and parents to sign a
form stating the student has the
maturity to self-administer relevant
medications. Although no specific
guidelines exist to determine when
it would be appropriate for a child
to self-carry and/or self-administer
epinephrine autoinjectors, a survey
of members of the AAP Section on
Allergy and Immunology found that
most pediatric allergy specialists
begin to expect children 9 through
11 years of age to be able to recognize
signs and symptoms of anaphylaxis
and expect children 12 through 14
years of age to self-carry epinephrine
autoinjectors and self-administer
the device. 11 In a study of family and
nonfamily caregivers of children with
food allergy, most expected the child
to be able to recognize anaphylaxis
at approximately 6 through 8 years
of age and believed that epinephrine
autoinjector use was appropriate
for children 6 through 11 years of
age. 15 Thus, these decisions may
benefit from personalization with
the input of the family. Of note, if it
is determined that self-carrying/
self-administration is appropriate,
it is important to designate adults
e2 by guest on June 26, 2020www.aappublications.org/newsDownloaded from
PEDIATRICS Volume 139 , number 3 , March 2017
to be additionally and primarily
responsible for treatment, because
the child may not be depended on to
self-treat if he or she is panicked or
severely symptomatic.
Treatment Pathways
Epinephrine is the first-line
treatment of anaphylaxis; therefore,
the form indicates that if there is
any uncertainty about whether
anaphylaxis is occurring, epinephrine
should be administered immediately.
The early use of epinephrine has
been shown to be associated with
better outcomes. In studies of
fatal and near-fatal anaphylaxis,
delayed or lack of administration
of epinephrine was noted in
the majority of cases. 13 Studies
have shown that the early use of
epinephrine in the treatment of food-
induced anaphylaxis was associated
with a decreased likelihood the child
would require hospital admission. 16, 17
Therefore, the plan instructs on
prompt treatment with epinephrine
for symptoms of anaphylaxis.
When allergic reactions are
suspected, the caregiver or school
personnel should observe for signs
and symptoms of an allergic reaction
and determine the appropriate
treatment pathway as outlined on
the allergy and anaphylaxis
emergency plan (Fig 1). If any severe
symptom develops, anaphylaxis
is highly likely, and epinephrine
should be injected immediately. 1, 5
Epinephrine administration
should be followed by activation
of emergency medical services
(calling 911), monitoring of the child,
and consideration of adjunctive
treatment with oral antihistamines
and/or bronchodilators for known
asthmatics or in the presence of
respiratory symptoms, including
wheezing or shortness of breath.
In some circumstances, it may be
beneficial to treat with epinephrine
even if anaphylaxis is not occurring,
such as when anaphylaxis is likely to
develop after an exposure or when
it may be difficult to determine
by the observer. Therefore, the
plan provides options that can be
selected at the physician’s discretion
to address these possibilities. For
example, if the child has a history
of very severe anaphylaxis, such
as with respiratory distress,
hypoxia, hypotension, or neurologic
compromise after exposure to
specific allergen(s), then the
health care provider may consider
recommending epinephrine to be
administered immediately after a
likely ingestion or sting at the onset
of the first symptom (even mild ones,
such as itchiness of the face/mouth,
a few hives, or mild symptoms of
stomach discomfort or nausea),
because severe reactions can
progress rapidly. 6, 18 Other scenarios
in which to consider immediate
epinephrine use after definitive
ingestion or sting when only mild
symptoms are present (assuming
additional doses are available,
should symptoms emerge and
progress) may include a child who
has a history of repeated anaphylaxis
with exposure to the specific
allergen(s), a child who has a history
of significant reactions with trace
exposures, or a child with comorbid
asthma that is poorly controlled.
The allergen(s) can be listed as a
“special situation” (box within the
“For Severe Allergy and Anaphylaxis”
box on the left-hand side of the
form). Although controversial, 19
there may be situations in which the
health care provider may consider
recommending epinephrine to be
administered immediately after a
definite ingestion or sting and before
symptoms develop (manually write
in “no” in place of “mild”), because
severe reactions can occur suddenly
without significant warning signs. 18
An example is if a child has had a
history of severe cardiovascular
collapse to a specific allergen. These
suggestions are based on expert
opinion, not from data acquired
through controlled trials.
In some situations, licensed
health care providers will not
be available in a school setting
and there is a desire to simplify
the instructions for delegates or
designated individuals. In these
cases, the health care provider can
indicate that definitive allergen
exposures would require immediate
treatment with epinephrine. If the
administration of antihistamine by
delegates or designated individuals
is not permitted by school or local
regulations, this scenario would be
another in which the health care
provider should consider instructing
epinephrine to be used in the event
of a definite allergen exposure even
if mild symptoms occur (see below
for more details on the completion
of the form for no permission to use
antihistamine).
If there is a mild symptom alone,
an oral antihistamine may be
administered first. If additional
symptoms are observed after oral
antihistamine has been administered
or if more than 1 organ system
is involved, then epinephrine
is indicated. Education about
anaphylaxis and epinephrine is
helpful, and additional advice about
the administration of epinephrine
is provided in another AAP clinical
report. 5
The use of antihistamine is
included as an option because
this plan provides instructions
for managing allergic reactions
with a range of severities. Several
studies have examined allergic
reactions attributable to accidental
or intentional exposures in food-
allergic children and noted that
30% to 70% of reactions are
characterized as mild in severity.
In a cohort of 512 young children
(3–15 months at enrollment) with
allergies to milk, egg, and/or peanut
followed over 3 years, 70% of the
1171 reactions occurring during the
study time frame were considered
to be mild (defined as skin and/or
oral symptoms and/or upper
e3 by guest on June 26, 2020www.aappublications.org/newsDownloaded from
FROM THE AMERICAN ACADEMY OF PEDIATRICS
respiratory symptoms, but not all 3
organ systems). 20 In a study in 88
children with milk allergy (median
age: 32.5 months) followed for 1
year, 53% of reported reactions
were mild (defined as cutaneous
symptoms [angioedema excluded],
rhinitis, or conjunctivitis). 21 A
recent Canadian study of accidental
exposures to peanut in 1941 children
(mean age: 7 years) with confirmed
peanut allergy reported that 30%
of exposures resulted only in mild
symptoms (defined as involving
only pruritus, urticaria, flushing, or
rhinoconjunctivitis). 22 Therefore, in
the event of a mild allergic reaction
involving isolated skin symptoms,
mild facial or oral symptoms, or mild
gastrointestinal tract discomfort,
none of which meet the criteria
for anaphylaxis, the use of oral
antihistamines may be an option.
Another concern is that if
epinephrine is stipulated in all cases
of allergic reaction regardless of
severity, a child may be hesitant
to voice any symptoms for fear
of epinephrine autoinjector use.
Thus, emphasizing the option to
observe and also having the option
of using antihistamines for mild
allergic reactions allows the plan to
be individualized according to the
child’s history. However, it is not
possible to know the eventuality
of any allergic reaction, and
consideration can be given to use
epinephrine liberally. If an option
is needed where antihistamine
alone is not permitted (eg, if school
or local policies do not permit
delegates or designated individuals
to administer antihistamines), then
no antihistamine would be listed
under medications. In this situation,
mild symptoms would not be treated
and close observation and watching
for possible progression would
be indicated. However, there is an
option to list all of the allergens
under “special situation” to indicate
that any symptoms would require the
administration of epinephrine.
After initiating treatment, additional
instructions for contacting
emergency medical services (calling
911) and monitoring for progression
of symptoms are provided on the
plan. For those who are initially
treated with epinephrine, a second
dose of epinephrine can be given
if symptoms persist or recur. For
those who are observed only or for
those who receive antihistamines as
the first treatment, any progression
of symptoms would warrant
epinephrine use, and the use of an
antihistamine should not delay the
administration of epinephrine.
In some severe cases of anaphylaxis,
rapid vasodilation and extravasation
of fluid have been reported, resulting
in a decrease of up to a 35% in
circulating blood volume within
minutes. 23 Upright posture in cases of
food-induced anaphylactic shock has
been reported to be associated with
fatalities. 24 This “empty ventricle
syndrome” has not been reported
in children; however, it would be
prudent to place the child in the
supine position to prevent pooling
of blood in the lower extremities
after epinephrine is administered.
This position may not be tolerated
in some circumstances, such as if a
child is vomiting or having difficulty
breathing. In these situations, the
child can be placed in the lateral
decubitus position (lying on his or
her side).
Medications
Medications, specifying dosage,
should be clearly indicated at the
bottom of the form. Standard dosing
for epinephrine in the treatment of
anaphylaxis in health care settings is
0.01 mg/kg, intramuscularly, with the
use of a 1:1000 dilution (maximum
of 0.3 mg in a prepubertal child and
0.5 mg in a teenager). Intramuscular
injection of epinephrine in the
lateral thigh is the preferred route
of administration because it results
in higher and faster peak plasma
concentrations than subcutaneous
or intramuscular injection in the
deltoid. 25
Providing epinephrine ampules,
needles, and syringes to patients and
families for weight-based dosing is
often not practical and subject to
human error; therefore, epinephrine
autoinjectors are prescribed for use
in the community setting. Currently,
only 2 epinephrine autoinjector
dosing options exist, 0.15 mg or
0.3 mg. Package inserts state that
the 0.15-mg dose is appropriate for
children weighing 15 to 30 kg, and
the 0.3-mg dose should be prescribed
for those who weigh greater than or
equal to 30 kg. On the basis of the
lack of readily available alternatives
and the favorable benefit-versus-risk
ratio, prescription of the 0.15-mg
autoinjector can be considered for
those weighing 7.5 to 15 kg. 5 Because
of the concern of underdosing in
children nearing 30 kg, expert
consensus suggests that children
be switched to the 0.3-mg dose
autoinjector when they reach 25 kg,
with consideration of switching to
this higher dose at a lower weight
if the child has asthma or other
risk factors for severe reaction. 5
Physicians can discuss the rationale
for selecting autoinjector doses
with each individual family. Two
epinephrine autoinjectors should
be available at all times, because
a second administration may be
needed if there is not a quick or
adequate response to the first dose of
epinephrine.
H1 antihistamines are effective for
the treatment of acute cutaneous
symptoms, such as pruritus
and urticaria, associated with
allergy. 26 Therefore, in cases of
isolated mild symptoms, the use
of oral antihistamines may be
appropriate. Diphenhydramine
is the most commonly used H1
antihistamine. Standard dosing
is 1 mg/kg, up to 50 mg. First-
generation H1 antihistamines,
such as diphenhydramine, cross
the blood-brain barrier, causing
e4 by guest on June 26, 2020www.aappublications.org/newsDownloaded from
PEDIATRICS Volume 139 , number 3 , March 2017
sedation and impairment in
cognitive function. These side
effects can potentially complicate
the neurologic assessment of a child
who is experiencing an allergic
reaction. These adverse effects are
significantly less likely to occur for
second-generation H1 antihistamines,
because these medications cross
the blood-brain barrier to a much
lesser extent. 26 In a randomized
double-blind study of 70 allergic
reactions during oral food challenge,
cetirizine (second-generation H1
antihistamine) was shown to have a
similar efficacy and onset of action
compared with diphenhydramine in
treating cutaneous symptoms during
acute food-induced allergic reactions.
Given these findings, in addition
to the longer duration of action
compared with diphenhydramine,
cetirizine is a good option to consider
for the treatment of isolated mild
symptoms of an allergic reaction. 27
Additional Instructions Regarding Completion of the Emergency Plan
Space is provided for parents’ and
health care providers’ signatures as
an additional measure to indicate
parental understanding and
agreement with the allergy and
anaphylaxis emergency plan. Space is
provided to indicate the dates of the
parents’ and health care providers’
signatures.
The second page provides space
for additional instructions, such
as statements of disability. Space
is provided to include contact
information for health care providers,
parents/guardians, and other
caregivers.
There is blank space on the second
page that can be used to provide
information specific to the school
or child or illustrations of using the
autoinjector.
The plan is given to the patient and
his or her family so they may review
it and share it with the school or
other child care facility or caregivers.
The health care provider may speak
to the family regarding the benefits
of permitting 2-way sharing of
information between the school
and the health care provider and
completing any forms that would be
required to allow this exchange of
information.
In addition to providing this allergy
and anaphylaxis emergency plan,
the patient should have updated
prescriptions for emergency
medications. It is also helpful for
the health care provider to review
with the patient and/or family
members instructions for, and show
the proper use of, epinephrine
autoinjectors by using a training
device that has the same mechanism
but does not contain medication
or the needle. Patients and family
members should be reminded to
check expiration dates on their
epinephrine autoinjectors and
be familiar with proper storage
conditions. Additional information
about anaphylaxis management is
reviewed in another AAP clinical
report. 5
SUMMARY
1. National and international
guidelines support the use of a
written allergy and anaphylaxis
emergency plan to enhance
the care of children at risk of
anaphylaxis. Although several
plans are currently available, they
differ in content and treatment
recommendations, potentially
leading to confusion. Thus, a
universal plan may be beneficial
to patients, families, health care
professionals, and schools.
2. An allergy and anaphylaxis
emergency plan, developed by
the health care provider, would
be beneficial for patients who are
at risk of anaphylaxis and those
who have been prescribed an
epinephrine autoinjector.
3. The written plan may serve as
a guide for patients, family and
nonfamily caregivers, and school
personnel in the management of
allergic reactions.
4. Epinephrine is the medication of
choice for the initial treatment
of anaphylaxis, and early
administration is associated
with optimal outcomes. In the
event of a definite exposure to
an allergen that has previously
caused a severe reaction, or if
anaphylaxis develops, immediate
use of epinephrine is warranted.
If exposure to an allergen triggers
only a mild symptom, observation
only or initiating treatment
with an antihistamine may be
appropriate.
5. This allergy and anaphylaxis
emergency plan allows
health care providers the
opportunity to individualize the
treatment plan according to the
child’s history, family input, and
local regulations. Options and
considerations for completing the
plan are reviewed in this clinical
report.
AUTHORS
Julie Wang, MD, FAAP
Scott H. Sicherer, MD, FAAP
SECTION ON ALLERGY AND IMMUNOLOGY EXECUTIVE COMMITTEE, 2015–2016
Elizabeth Matsui, MD, FAAP, Chair
Stuart Abramson, MD, PhD, FAAP
Chitra Dinakar, MD, FAAP
Anne-Marie Irani, MD, FAAP
Jennifer S. Kim, MD, FAAP
Todd A. Mahr, MD, FAAP, Immediate Past Chair
Michael Pistiner, MD, FAAP
Julie Wang, MD, FAAP
LIAISON
Paul V. Williams, MD, FAAP – American Academy of
Allergy, Asthma, and Immunology
STAFF
Debra Burrowes, MHA
e5
ABBREVIATION
AAP: American Academy of
Pediatrics
by guest on June 26, 2020www.aappublications.org/newsDownloaded from
FIGURE 1AAP Allergy and Anaphylaxis plan.
by guest on June 26, 2020www.aappublications.org/newsDownloaded from
FIGURE 1Continued
by guest on June 26, 2020www.aappublications.org/newsDownloaded from
FROM THE AMERICAN ACADEMY OF PEDIATRICS
REFERENCES
1. Sampson HA, Muñoz-Furlong A,
Campbell RL, et al. Second Symposium
on the Defi nition and Management
of Anaphylaxis: summary report—
Second National Institute of Allergy
and Infectious Disease/Food
Allergy and Anaphylaxis Network
Symposium. J Allergy Clin Immunol.
2006;117(2):391–397
2. Simons FE, Ardusso LR, Bilò MB,
et al; World Allergy Organization. World
Allergy Organization guidelines for
the assessment and management of
anaphylaxis. World Allergy Organ J.
2011;4(2):13–37
3. Lieberman P, Nicklas RA, Oppenheimer
J, et al The diagnosis and management
of anaphylaxis practice parameter:
2010 update. J Allergy Clin Immunol.
2010;126(3):477–480, e1–e42
4. Muraro A, Roberts G, Worm M, et al;
EAACI Food Allergy and Anaphylaxis
Guidelines Group. Anaphylaxis:
guidelines from the European Academy
of Allergy and Clinical Immunology.
Allergy. 2014;69(8):1026–1045
5. Sicherer SH, Simons FE; Section
on Allergy and Immunology. Self-
injectable epinephrine for fi rst-aid
management of anaphylaxis [published
correction appears in Pediatrics.
2007;119(6):1271]. Pediatrics.
2007;119(3):638–646
6. Sicherer SH, Mahr T; Section on Allergy
and Immunology. Management of
food allergy in the school setting.
Pediatrics. 2010;126(6):1232–1239
7. Council on School Health. Medical
emergencies occurring at school.
Pediatrics. 2008;122(4):887–894
8. Centers for Disease Control and
Prevention. Voluntary Guidelines for
Managing Food Allergies in Schools
and Early Care and Education
Programs. Washington, DC: US
Department of Health and Human
Services; 2013
9. Gibson PG, Powell H, Coughlan J,
et al. Self-management education and
regular practitioner review for adults
with asthma. Cochrane Database Syst
Rev. 2003;1:CD001117
10. Nurmatov U, Worth A, Sheikh A.
Anaphylaxis management plans for the
acute and long-term management of
anaphylaxis: a systematic review.
J Allergy Clin Immunol.
2008;122(2):353–361, e1–e3
11. Simons E, Sicherer SH, Simons FE.
Timing the transfer of responsibilities
for anaphylaxis recognition and use
of an epinephrine auto-injector from
adults to children and teenagers:
pediatric allergists’ perspective.
Ann Allergy Asthma Immunol.
2012;108(5):321–325
12. Bock SA, Muñoz-Furlong A, Sampson
HA. Fatalities due to anaphylactic
reactions to foods. J Allergy Clin
Immunol. 2001;107(1):191–193
13. Bock SA, Muñoz-Furlong A, Sampson
HA. Further fatalities caused by
anaphylactic reactions to food,
2001-2006. J Allergy Clin Immunol.
2007;119(4):1016–1018
14. Turner PJ, Gowland MH, Sharma V,
et al. Increase in anaphylaxis-related
hospitalizations but no increase
in fatalities: an analysis of United
Kingdom national anaphylaxis data,
1992-2012. J Allergy Clin Immunol.
2015;135(4):956–963, e1
15. Simons E, Sicherer SH, Weiss C,
Simons FE. Caregivers’ perspectives on
timing the transfer of responsibilities
for anaphylaxis recognition and
treatment from adults to children
and teenagers. J Allergy Clin I
mmunol Pract. 2013;1(3):
309–311
16. Fleming JT, Clark S, Camargo CA Jr,
Rudders SA. Early treatment of food-
induced anaphylaxis with epinephrine
is associated with a lower risk of
hospitalization. J Allergy Clin Immunol
Pract. 2015;3(1):57–62
17. Gold MS, Sainsbury R. First aid
anaphylaxis management in children
who were prescribed an epinephrine
autoinjector device (EpiPen). J Allergy
Clin Immunol. 2000;106(1 pt 1):
171–176
18. American Academy of Allergy, Asthma,
and Immunology Board of Directors.
Anaphylaxis in schools and other
childcare settings. J Allergy Clin
Immunol. 1998;102(2):173–176
19. Turner PJ, DunnGalvin A, Hourihane
JO. The emperor has no symptoms:
the risks of a blanket approach to
using epinephrine autoinjectors for
all allergic reactions. J Allergy Clin
Immunol Pract. 2016;4(6):
1143–1146
20. Fleischer DM, Perry TT, Atkins D,
et al. Allergic reactions to foods
in preschool-aged children in a
prospective observational food
allergy study. Pediatrics. 2012;130(1).
Available at: www. pediatrics. org/ cgi/
content/ full/ 130/ 1/ e25
21. Boyano-Martínez T, García-Ara C,
Pedrosa M, Díaz-Pena JM, Quirce
S. Accidental allergic reactions
in children allergic to cow’s milk
proteins. J Allergy Clin Immunol.
2009;123(4):883–888
22. Cherkaoui S, Ben-Shoshan M,
Alizadehfar R, et al. Accidental
exposures to peanut in a large cohort
of Canadian children with peanut
allergy. Clin Transl Allergy. 2015;5:16
23. Fisher MM. Clinical observations on
the pathophysiology and treatment
of anaphylactic cardiovascular
collapse. Anaesth Intensive Care.
1986;14(1):17–21
24. Pumphrey RS. Fatal posture in
anaphylactic shock. J Allergy Clin
e8
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2017 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they do not have a fi nancial relationship relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to disclose.
by guest on June 26, 2020www.aappublications.org/newsDownloaded from
PEDIATRICS Volume 139 , number 3 , March 2017
Immunol. 2003;112(2):
451–452
25. Simons FE. First-aid treatment
of anaphylaxis to food: focus on
epinephrine [published correction
appears in J Allergy Clin Immunol.
2004;113(6):1039]. J Allergy Clin
Immunol. 2004;113(5):837–844
26. Simons FE, Simons KJ. Histamine
and H1-antihistamines: celebrating
a century of progress. J Allergy Clin
Immunol. 2011;128(6):1139–1150, e4
27. Park JH, Godbold JH, Chung D,
Sampson HA, Wang J. Comparison of
cetirizine and diphenhydramine in
the treatment of acute food-induced
allergic reactions. J Allergy Clin
Immunol. 2011;128(5):1127–1128
e9 by guest on June 26, 2020www.aappublications.org/newsDownloaded from
DOI: 10.1542/peds.2016-4005 originally published online February 13, 2017; 2017;139;Pediatrics
Julie Wang, Scott H. Sicherer and SECTION ON ALLERGY AND IMMUNOLOGYGuidance on Completing a Written Allergy and Anaphylaxis Emergency Plan
ServicesUpdated Information &
http://pediatrics.aappublications.org/content/139/3/e20164005including high resolution figures, can be found at:
Referenceshttp://pediatrics.aappublications.org/content/139/3/e20164005#BIBLThis article cites 26 articles, 4 of which you can access for free at:
Subspecialty Collections
ubhttp://www.aappublications.org/cgi/collection/allergy:immunology_sAllergy/Immunologyfollowing collection(s): This article, along with others on similar topics, appears in the
Permissions & Licensing
http://www.aappublications.org/site/misc/Permissions.xhtmlin its entirety can be found online at: Information about reproducing this article in parts (figures, tables) or
Reprintshttp://www.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:
by guest on June 26, 2020www.aappublications.org/newsDownloaded from
DOI: 10.1542/peds.2016-4005 originally published online February 13, 2017; 2017;139;Pediatrics
Julie Wang, Scott H. Sicherer and SECTION ON ALLERGY AND IMMUNOLOGYGuidance on Completing a Written Allergy and Anaphylaxis Emergency Plan
http://pediatrics.aappublications.org/content/139/3/e20164005located on the World Wide Web at:
The online version of this article, along with updated information and services, is
by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397. the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2017has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
by guest on June 26, 2020www.aappublications.org/newsDownloaded from